Pediatrix Medical Group, Inc. (MD) Q4 2012 Earnings Report, Transcript and Summary

Ladies and gentlemen, thank you for standing by. Welcome to the MEDNAX fourth quarter earnings call. At this time all participants are in a listen-only mode. You will have an opportunity to ask questions after the presentation. Instructions will be given at that time. As a reminder, this call is being recorded. I would now like to turn the conference over to our host, Mr. David Parker. Please go ahead.

Great, thank you Mary and welcome everyone to our fourth quarter 2012 investor conference call. Certain statements and information during this conference call maybe deemed to be forward-looking statements within the meaning of the Federal Private Securities Litigation Reform Act of 1995. These forward-looking statements are based on assumptions and assessments made by MEDNAX's management in light of their experience and their perception of historical trends, current conditions, expected future developments and other factors they believe to be appropriate. Any forward-looking statements made during this call are made as of today, and MEDNAX undertakes no duty to update or revise any such statements, whether as a result of new information, future events, or otherwise. Important factors that could cause actual results, developments, and business decisions to differ materially from forward-looking statements are described in the company's most recent Annual Report on Form 10-K, and its Quarterly Reports on Form 10-Q, including the sections entitled Risk Factors. With that, I would now like to turn the call over to our CEO Dr. Roger Medel. Roger.

Thank you, David. Good morning and thanks for joining our call today. As we've reported in our release earlier this morning, we achieved solid earnings results for the fourth quarter and full year of 2012. These results are primarily driven by our proven national medical group factors model of attracting acquiring, and successfully integrating physician group practices, and we're very encouraged by the strategic roadmap that we have planned out for 2013, which reflects our very full and robust acquisition pipeline. Some of the key points that makes the MEDNAX model different, such as an evolutionary rather than a revolutionary approach to growth, a determined focus on bringing value to physicians and hospital partners, extensive clinical research, education and quality efforts, and a proven track record over decades provide the solid foundation from which we continue to strategically grow. In looking at a few highlights, our revenue for the fourth quarter increased by over 16%, with growth attributable to contributions from recently acquired practices at over 13%, and the remainder coming from our same unit results. We also have double-digit net income growth for the fourth quarter and full-year, and generated strong cash flow from operations for both periods as well, which was noted in our press release. We have the financial strength and flexibility to fund the future growth through internal cash generation, and our $800 million revolving credit facility, but at the same time building upon the solid foundation we've established to manage our existing operations. We believe that success of our model supported by a proven platform, and clearly defined long-term growth opportunities continues to define the future of healthcare, and to differentiate MEDNAX in the [promotional] healthcare marketplace. What I will cover over the next few minutes is the progress that we continue to make as we execute this proven long-term growth strategy for both our American Anesthesiology and Pediatrix Medical Group platforms. We completed a very successful 2012 in terms of practices joining our National Medical Group as we discussed on our 2012 acquisition summary call a few weeks ago. 16 physician group practices joined MEDNAX in 2012, eight as part of American Anesthesiology, and eight as part of Pediatrix Medical Group. These acquisitions reflect the debts of our pipeline, as well as the strength of our business development and integration efforts. Focusing on late 2012 additions and future growth prospects for American Anesthesiology, in November we added DeKalb Anesthesia Assistants in Decatur, Georgia. In December, we added two additional group practices, first South Oakland Anesthesia Associates, a group that provide services throughout Oakland County Michigan and well also the first Michigan-based practice to joint the division. We also acquired Anesthesiologist Associated in the Chattanooga, Tennessee and Metropolitan area, the second Tennessee-based practice to joint our division. With the eight Anesthesiology acquisitions we completed during 2012. Our American Anesthesiology division now consists of more than 1,475 anesthesia providers including more than 600 physicians and 875 anesthetists practicing now in eight states. With respect to our recent additions to the Pediatrix Medical Group division, in November we added a pediatric hospitalist program in Orlando, Florida. In December, we added a one physician Maternal-Fetal Medicine Practice in the Atlanta area. And also in December, we acquired Plano, Texas based pediatric surgical associates, the second pediatric surgery group to joint the Pediatrix Medical Group division both in Texas. With these three acquisitions in the fourth quarter and the total of eight practices acquired during 2012, our Pediatrix Medical Group division, now consist over 1,400 neonatologists and related Pediatrix subspecialists practicing in 34 states. Of the eight practices acquired during the year, two were pediatric cardiology, two were maternal-fetal medicine, one was neonatology, one was pediatric intensive care, one was a group of pediatric hospitalists and one with pediatric surgery. Our additions to the Pediatrix Medical Group division throughout all of 2012 reflect an important point that I've mentioned earlier. We continue to take an evolutionary approach to growth in the division. On previous calls, we talked about expanded growth avenues in addition to acquisitions including organic growth. We start our programs such as some of the pediatric hospitalists programs that we would in place, while we've been pursuing this expended growth avenues, the marketplace of our hospital partners have evolved as well. Healthcare reform hospital provider consolidation, structural reimbursement changes and pressures, and impacts on margins that all led to a more competitive landscape for hospitals. As a result of the structural changes within healthcare, our hospital partners are changing how they execute their strategies, and they are looking to providers such as MEDNAX to join them in addressing these changes. In doing so, we continue to work with our hospital partners to develop integrated service programs for which will be come a multi-specialty provider of solutions within the maternal-fetal, new born, and the pediatric continuum of care. These integrated programs result in a broader cross specialty of care and patient service line extensions into our market. An example of this is our effort in conjunction with our hospital partner at Centennial Medical Center in the Nashville Tennessee Area. In 2009, we acquired Mid-Tennessee Neonatology Associates, a physician group practice that manages the neonatal intensive care unit at Centennial and other hospitals in the Nashville Area. This has been a successful partnership over the last few years, and one in which the discussion between Pediatrix Medical Group and our hospital partner evolve into looking at how we could work with them to put in place the building blocks around an integrated children's services program. Centennial was interested in further addressing their marketplace via services that would complement the hospital in terms of a women and children's program, while we were interested in organic growth initiatives beyond our neonatal intensive care unit that will provide additional patient care services to complement the NICU process. As a result, we worked with Centennial to add pediatric intensive care, pediatric surgery, and a pediatric hospitals program to support their marketplace and provide them incremental growth, while at the same time providing organic growth and patient service line extensions around our NICU presence at Centennial Medical Center. We are currently executing this market partnership successfully in other metropolitan areas, and were actively pursuing similar opportunities at the request of our existing hospital partners, as well as new hospital affiliations. We believe we can successfully establish pediatrics as our multi-specialty provider of solutions within the maternal-fetal, new born pediatric continuum of care. , : With that, at this time, I'd like to turn the call over to our Chief Financial Officer Vivian Lopez Blanco for a review of our fourth quarter and full-year 2012 financial results. Vivian? With that, at this time, I'd like to turn the call over to our Chief Financial Officer Vivian Lopez Blanco for a review of our fourth quarter and full-year 2012 financial results. Vivian?

Thanks Roger, good morning and thanks for joining our call. Our results for the fourth quarter and full-year 2012 reflect solid growth in revenue, operating income, and net income growth, coupled for strong cash flow from operations available for investing back into our business. And on that front as Roger mentioned, we invested over $450 million during 2012 to complete 16 group practice acquisitions. Net patient service revenue for the three months ended December 31, 2012, increased by 16.4% to $471.3 million from $404.9 million for the comparable prior year period. Our revenue growth attributable to contribution from recently acquired practices was 13.3%, while same-unit revenue grew by 3.1% for the 2012 fourth quarter when compared to the prior year period. Of this 3.1% same-unit growth revenue attributable to volume grew by 2.2%, while net reimbursement related factors grew by 0.9%. Same-unit growth attributable to patient volume was driven by growth in our hospital-based neonatal and other pediatric physician services, primarily new born nursery services as well as anesthesia services, and maternal-fetal medicine services partially offset by a decline in our office space pediatric cardiology services. For the 2012 fourth quarter, same-unit neonatal intensive care patient days increased 3% when compared to the prior year period, while the number of births at our hospital also same-unit was up 2.4%. Our same-unit revenue growth from net reimbursement-related factors was principally due to continued modest improvements in reimbursements received from third-party commercial payors as a result of the Company's ongoing contract renewal processes and the flow through of revenue from modest price increases, partially offset by a shift in payor mix to government payors from commercial payors, year-over-year. The percentage of services reimbursed under government programs increased by approximately 140 basis points during the 2012 fourth quarter compared to the prior year period. On a sequential basis, same-unit payor mix shifted by approximately 20 basis points toward a higher percentage of services reimbursed under government-sponsored programs. Our profit after practice expense for the 2012 fourth quarter was $161.4 million, up 14% from $141.6 million for the prior year period. Profit after practice expense margin decreased by 74 basis points, which can be attributed to the variability in margins due to the mix of practices acquired since October 2011. Increases in practice expenses primarily due to practice salary increases and increases an incentive compensation based on practice operational results. We generated operating income of $103 million for the 2012 fourth quarter, an increase of 12.6% from $91.5 million for the prior year period. General and administrative expenses grew by 17.3% to $50.3 million for the 2012 fourth quarter. As a percentage of revenue G&A expenses were slightly up during the 2012 fourth quarter compared to the prior year period. Depreciation and amortization expense for the 2012 fourth quarter remained essentially flat at 1.7% of revenue compared to the prior year period. Net income for the 2012 fourth quarter was $66.1 million, up 13.3% from $58.4 million for the 2011 period. Our diluted earnings per share increased by a 11% for the 2012 fourth quarter to $1.32 based on a weighted average $50.1 million shares outstanding, which compares with diluted earnings per share of $1.19 based on a weighted average $49.1 million shares outstanding for the 2011 fourth quarter. Moving on to our full year results, revenue for the full year ended December 31, 2012 was $1.82 billion, an increase of over $228 million or 14.4% from 2011 revenue of $1.6 billion. Of this $228 million increased over 78% or approximately $179 million of the revenue growth came from acquisitions, while the remainder is from same-unit growth, which increased by approximately $49.4 million for the full year 2012. Overall, same-unit revenue for the full year 2012 grew by 3.2%. More than half of this came from same-unit volume growth which was up 1.9% with volume growth in our hospital base, neonatal, other pediatric physician services, primarily new born nursery services and anesthesia, as well as our office-based maternal-fetal medicine services partially offset by a decline in our office-based pediatric cardiology services. The remainder came from same-unit revenue growth from reimbursement related factors, which was up 1.3% net with the driving factors being consistent with those that drove our fourth quarter increase that I previously mentioned, partially offset by a shift in payor mix to government payors from commercial payors year-over-year. Operating income grew to $389.5 million for the full year 2012, up 9.6% from $355.4 million for the full year 2011. Net income grew by 10.5% to $240.9 million, up from $218 million for last year, $4.85 based on a weighted average $49.7 million shares outstanding for the full year of 2012, up from $4.47 for the full year 2011, based on $48.8 million shares outstanding. Looking at our balance sheet, we had cash and cash equivalents of $21.3 million at December 31, 2012. Accounts receivable at December 31, 2012 were $248.1 million, an increase of approximately $18 million as compared to December 31, 2011. The growth in our AR is related to recently acquired practices as well as same-unit revenue growth. Day sales outstanding improved by approximately 4 days to 48.4 days for the 2012 fourth quarter as compared to the fourth quarter of 2011, primarily as a result of improvement at existing units as well as the continued integration of our recent acquisitions. We had $144 million outstanding on our $800 million revolving credit facility at December 31, 2012. For the full year ended December 31, 2012, MEDNAX generated cash flow from operations of $325.7 million, including cash flow from operations of $106 million for the 2012 fourth quarter. This is an improvement from the prior year when we generated approximately $271 million of cash flow from operations for the full year ended December 31, 2011 including cash flow from operations of $90.1 million for the 2011 fourth quarter. The increase in cash flow from operations for the full year and three months ended December 31, 2012, is primarily due to improved operating results and an increase in cash flow related to accounts receivable. We invested over $450 million of cash during 2012 to fund 16 group practice acquisitions of which $244 million of cash was invested during the 2012 fourth quarter to fund six group practice acquisitions, and to make contingent purchase price payments for previously completed acquisitions. Moving onto our outlook for the 2013 first quarter, as we announced in this morning's press release, we expect that our earnings per share for the three months ending March 31, 2013, will be in a range of $1.05 to $1.10. The range for our 2013 first quarter outlook assumed anticipated same-unit revenue growth for the period, which we estimate to be 1% higher to 3% higher year-over-year on a total same-unit basis. The same-unit growth forecast is expected to be divided evenly between patient volume assuming growth across all of our MEDNAX physician specialties, and net reimbursement growth, including improvements from commercial payor contracts, offset by variability in the mix of services reimbursed under government payor programs. As a reminder, we have experienced increases in the percentage of patient services being reimbursed under government payor programs in recent periods. We are also expecting that our effective tax rate for the 2013 first quarter will be consistent with that we experience in the comparable 2012 period, which is higher than that for the 2012 fourth quarter. For the full year 2013, we expect the tax rate to be in line with 2012. For all of 2013 MEDNAX expects to invest approximately $400 million to complete practice acquisition across all MEDNAX physician specialties, the majority of which we expect to invest in our American Anesthesiology division and the remainder in our Pediatrix Medical Group division. As a result of the acquisitions that we had completed in recent years we've experienced variability in our operating margins. Consistent with this trend, we expect this variability in our operating margins to continue as a result of the mix and timing of acquisitions. This impact is included in our financial outlook for the first quarter 2013, and is expected to continue to have an impact in future periods. For those who have followed MEDNAX for sometime, you'll remember that our results for the first quarter of every year are impacted by some timing issues that affect our results on a sequential basis. For the first quarter of 2013, these factors include impact on net patient service revenue, because there are fewer calendar days than in the fourth quarter, as well as a significant increase in expenses associated with social security taxes that are higher at the start of each year when compared to the fourth quarter of the prior year due to the significant number of our employees primarily our physicians exceeding the level of taxable wages for social security during the first and second quarters. These recurring items impact our operating income, net income, and earnings per share and are included in our financial outlook for the 2013 first quarter. It's also important to remember that we typically have negative cash flow from operations during the first quarter of every year, as we use cash and amounts under our revolving credit facility to pay bonuses based on our practice operational results as well as discretionary matching contributions for participants in our 401(k) plans that have accrued throughout the prior year. As a result of these uses of cash in the 2013 first quarter, and the acquisitions that we completed late in 2012, we will incur an increase in interest expense associated with higher borrowings outstanding under our revolving credit facility. This additional interest expense is also included in our financial outlook for the 2013 first quarter. Now, I will turn the call back over to Roger.

Thank you, Vivian. Operator, let's go ahead and open up the call for questions, please.

(Operator Instructions) Our first question comes from the line of Ryan Daniels with William Blair. Please go ahead. Ryan Daniels – William Blair: Yeah guys, good morning. Thanks for taking my question. Roger, first off a question for you. You talked little about establishing the pediatric continuum of care with your hospital partners. So, I guess two questions there. When you look to do that are you acquiring those physician groups to try to employ doctors, or maybe taking them from the hospital? And then, second question related, do you have any data yet to show what kind of same store uplift you might see on the organic growth basis when you put those continuum of care programs in place?

Yeah. Hi, good morning, Ryan. Typically, we don't acquire these practices. These are typically practices that the hospital either ask us to put together for them, or to assume the responsibility for, but these are not typically acquisitions. I don't yet have a same store number for that side of the practice that I can give you. Ryan Daniels – William Blair: Okay, and then just as a quick follow-up on the Medicaid to Medicare parity. Can you just talk a little bit about your impressions of how that's going to take place? It seems like the states individually need to pass legislation and retroactively make that back to January 1st. Just any color you have on how that's going to rollout, and if you think all the states will come on mid-year, if it's going to be sporadic though the year, just any color you have there?

Yeah, we have done a lot of work on that, and we do have some information. Basically, each state is going to do it differentially. They are – but right now, I think Utah is the only one that has a [method] of the requirements but all of the other states are still working on their issues and some are planning on doing it, along some others are talking about just increasing the payment to the physicians. Other than just saying that we do think that we are going to get paid, we probably will see some money during the second quarter and each date is going to have its own process to go through. We really can't say much more than that at this point in time. Vivian do you add anything to that.

Yeah, so Ryan it's basically, what we've been saying all over, we have a work group here that's comprised; they have a lot of different functional areas namely our patient's accounts and managed care folks that are reaching after each one of our state. So as Roger mentioned, they really have until the end of March to turn in these applications. And then after that CMS reviewed these applications and agreed to the method that they are staying that is how they are going to be reimbursing that the providers that basically have said that they are part of the program. And so we are in the process with all of that, as Roger said there is only one or two states that have submitted their applications. And so we'll see how it goes, right now we don't anticipate any issue with it other than we from a practical perspective. I agree with Roger, we probably will not see, the money to the second quarter, because it's just not going to be the practical based on this timeline, but other than that it's just how they are going to implement the rule. Ryan Daniels – William Blair: Okay, that's helpful color. Thanks guys.

And our next question comes from the line of Kevin Ellich with Piper Jaffray. Please go ahead. Kevin Ellich – Piper Jaffray & Co.: Good morning, thanks for taking the questions. I guess I want to start-off with the same store growth; it was good to see same store and NICU up 3%. I was just wondering what you are seeing obviously (inaudible) good detail on the hospitals, but what about the non-NICU volume growth. It seems like that might be under some pressure?

Good morning, Kevin. Yes, so this is Vivian. So, really as I mentioned all of our specialties with the exception of pediatric cardiology had pretty good volume growth. So, we're really happy with the volume in all of them. And so, yes, the NICU for the last couple of quarters as we have talked about, we've been encouraged with the birth rate et cetera, but the other specialties, all have had a very respectable volume growth. Kevin Ellich – Piper Jaffray & Co.: Okay, that's helpful, sorry I missed that. And then now that you guys have done a number of anesthesia acquisitions. Roger, I was wondering if you could tell us how they performing, what type of same-store growth are you seeing out of those practices, are they living up to your expectations and any color you could provide would be helpful.

Yeah, well, the first thing I would talk about is the quality of the groups that we have. I'm just so proud of these guys, it's really a pleasure for me to see how interested they are in their specialty and then providing great care for their patients, and that's just really exciting for me to see. Kevin Ellich – Piper Jaffray & Co.: Got it. And then just following-up on that for the deals, do you have any updated thoughts on timing, I know you took a little hiatus in January, but are you guys, do you expect to get some deals done here in February?

Kevin Ellich – Piper Jaffray & Co.: Okay, excellent. Thank you.

Thank you.

Our next question comes from the line of Ralph Giacobbe with Credit Suisse. Please go ahead. Ralph Giacobbe – Credit Suisse: Thanks, good morning.

Good morning. Ralph Giacobbe – Credit Suisse:

, : Ralph Giacobbe – Credit Suisse: And just remind me, I mean, because I think most of the deals in 2012 were back end loaded. I don't know that there were many deals at all in the first quarter, so is that fair?

Well, we did have some deals throughout the years, and we did have some deals in the first quarter, yes, but the big deals, there were several of the big deals that occurred in the fourth quarter, but we did have deals throughout the year. Ralph Giacobbe – Credit Suisse: I guess on sort of back in the envelope, based on sort of our assumptions around some of those revenue, revenue contribution in the first quarter, it just looks like EBITDA margin levels would drop to that kind of 19% level in 1Q to just get to your range within guidance. And, I know 1Q is always seasonally lighter, but that base just seems a little bit lower than what we've seen historically, I'm just struggling with it, is that a function of new deals on lower margins that ramp up over time, or pressure on existing business given the mix, help me sort of reconcile that lower margin.

Yeah, no so that's a good question, because I think that's a lot of the discussion around the first quarter consensus. I'm glad that that you bring it up, because I try to be as explicit as I could in the script. And we've been saying that as we continue to expand the anesthesia base, but really even some of these other continuous care specialties within the Pediatrix Division, we have seen that those margins are typically not in the range of the NICU margins usually. Again there is some exceptions to that with some of the anesthesia practices depending on their payor mix and their models. But for the most part that is correct that we'll continue to see some of that margin pressure because of the fact that we do have the mix of our practices changing and once we look at what we're going to be disclosing in our 10-K, basically we're going up to about 27% related to the percentage of revenue related to anesthesia. So that's a good point that you bring up, because I think that will be helpful as all of you guys put out some of the concession for the years and going forward, I think we have to look at the margins that way. Ralph Giacobbe – Credit Suisse: Okay. So trying to extrapolate that for the full year exclusive of parity and exclusive of further deals, too much to think that margins on a year-over-year basis should be down, year-over-year because of all the acquisitions within the mix of business where there is a lower margin.

Yeah, but it's a lot of things also. I mean, I have been saying this for a while now too. There is a lot of factors going in, in a lot of different ways, yes. Overall, we added a lot of providers obviously on the anesthesia basis. We added over 61% increase in providers. So there are going to be some infrastructure build as well on the G&A line as well as basically what's happening on the same unit line with increases in volume and last year we had pressure on payor mix, so that was another thing that I highlighted because the year before we had actually had some favorability in the payor mix, that would be 2011 and 2012. We did have some pressure with the payor mix, again at about a 120 basis points increase year-over-year and about a 140 in Q4. So all of these things together, is what's creating that pressure in the margins. Ralph Giacobbe – Credit Suisse: Okay. And then just one last one here. Maybe remind us of the target multiples for your deals within NICU and as well as anesthesiology and if there has been any change in the marketplace due to competition?

Yeah, there hasn't been any change. We are very disciplined about the multiples that we pay on that pediatrics, neonatology side that multiple is typically forward, a multiple of pro forma EBITDA. Ralph Giacobbe – Credit Suisse: Pro forma, okay.

Yeah, pro forma. We look at the practice and we say if we were managing this practice knowing the kinds of efficiency that we can bring to the practice. What kind of contribution could we expect from it and then we will put it on a four or so multiple on that, and that's what we are paying for the practices. On the anesthesia practices, we really haven't disclosed the multiples that we are paying, because there is more competition there and we don't really want to highlight that for our competition, but I will tell you that we are very disciplined on the multiples that we are very disciplined on the multiples that we pay for our practices, and we are not going outside of our model. Ralph Giacobbe – Credit Suisse: And, just to speak in one word, the NICU, the four times performer, have you given, or can you talk about what that would look like on a trailing basis?

Well, it could be infinite, right. These practices are typically take all the money out, if there are partnership, they distribute the money out to the partners at the end of the year in forms of bonuses, et cetera. So, it could be an infinite multiple on a trailing basis. Ralph Giacobbe – Credit Suisse: All right, thanks.

The next question comes from the line of Brooks O Neill with Dougherty & Company. Brooks O'Neill – Dougherty & Company: Good morning. Even though I've covered you for a long time, I am about to ask some dumb questions, and I apologize in advance. Firstly, I'm just curious obviously you had a pretty robust acquisition experience in the fourth quarter, but looking at it sequentially, which I know probably isn't the right way to look at it, revenue and earning were above flat 3Q to 4Q, and I'm just curious if you could comment on why that might be?

Well both those acquisitions we're done right at the end of December, so. Brooks O'Neill – Dougherty & Company: Yeah, so they didn't have much impact.

That's one thing, Vivian.

Yeah, there is the other thing. Brooks, remember that in the first quarter we basically have two less calendar days, so that would be other thing that I spoke about at the end of my discussion that for the first quarter it's not a comparable…

He was talking about comparing third quarter to fourth quarter.

Well, I thought it was comparing fourth quarter…

Right, okay. Brooks O'Neill – Dougherty & Company: Yeah, that's what I was asking about Roger.

Okay. Yeah, so to me the answer for that is just most of the acquisitions, the significant acquisitions in the fourth quarter were done right at the end of December.

Right. Brooks O'Neill – Dougherty & Company: Yeah. And we should still assume that you're doing acquisitions at a basis you consider to be immediately accretive, right?

That's correct.

Yes.

We would not do a diluted deal. Brooks O'Neill – Dougherty & Company: That's what I thought. And then, I am assuming guidance for the first quarter does not assume any positive impact from the parity adjustment at this point.

That is correct also. Brooks O'Neill – Dougherty & Company: Cool, and then I'm just guessing, but you tell me the answer to this that you're not seen any secular changes in the way we're managing baby is the percent of premature babies as a top component of the overall birth rate or for any of that stuff or maybe that's changing now?

No, not at all, we're seeing actually a little bit of increase in birth as I'm sure, you know. Brooks O'Neill – Dougherty & Company: Yeah.

Our mid rate for the fourth quarter is right inline as is our average length of days, so those are the two variables as you know that we follow pretty closely. They are moving up and down or few basis points here and there, but basically all within normal ranges. Brooks O'Neill – Dougherty & Company: Cool. And then the mix shift you're not seeing anything you consider startling in that, and just been kind of a gradual mix shift partly I mean when I guess knows exactly what its all about, but we assume maybe related to the softer economy, et cetera, but is there anything that really raise your eyebrows in that?

No, nothing that I – we've looked at that numerous times and we're not sure what's going on Vivian.

Yeah, I mean I agree with Roger, Brooks. Its just basically that continued variability, because frankly in 2011 we were quite happy with a fact that we had a favorable payor mix shift all throughout the year and the prior year to that, we had seen increases now, last year. Again, we saw some increases and so it just that continued variability, I do think to your point, we do have an overall sentiment, that is related to the macroeconomy obviously, we can't prove that, but it's just intuitively make sense. Brooks O'Neill – Dougherty & Company: Sure. Just one or two more quick questions. I am curious if you have any comments about kind of how you feel about your debt levels sort of where you'd be willing to take it, the right opportunities presented themselves, how you feel about your balance sheet at this point, particularly in light of the pipeline obviously?

Well, as far as line of credit is concerned, I'd like to tap it out here. And as we have said in the past, it's the right. I'm not opposed to putting some long-term debt on our both for the right reason. And if the right opportunity comes along to do a deal that would require us to do that. We would do it. That hasn't happened and we are not going to do it for financial exercises, I guess a couple of financial banks, investment bankers in my office a year talking about doing a convert with a flying saucer and a double back flip or something and we're just not going to do that. But for the right reasons, we will put some… Brooks O'Neill – Dougherty & Company: Okay, well, congratulations on continued great executions and then I am looking forward to 2013.

Thanks, Brooks. I appreciate your support.

The next question comes from the line of Kevin Fischbeck with Bank of America. Please go ahead. Kevin Fischbeck – Bank of America Merrill Lynch: Okay, thank you. Just wanted to confirm the acquisition number you talked about. The 451 obviously included earn outs from prior deals, is the 400 number you look at include earn outs from last year's deals that's just kind of pure new spending do you expect.

That's pure new spending. We wouldn't include that.

Yeah. That would be, I agree with Roger, it could have for the current year. It could have contingent payment. Yeah.

There'll with some contingent payments, so, yeah.

And there will be some contingent payments if that's what you are asking. In our estimates for what we will spend this year, we've not included that.

Right… Kevin Fischbeck – Bank of America Merrill Lynch: Okay. Just…

Yeah. Kevin Fischbeck – Bank of America Merrill Lynch: So, if you (inaudible) expected you to say that you spent 430 or something, or some number higher than that.

That's right. Kevin Fischbeck – Bank of America Merrill Lynch: Given the (inaudible), okay. And, I guess, if you just go back a little more to the commentary about trying to deepen the...

I am sorry, we lost you there, are you still there Kevin? Kevin Fischbeck – Bank of America Merrill Lynch: Yeah, I am here. Can you hear me?

Yeah, now we can. We lost you. Repeat the question. We lost you there at the end. Kevin Fischbeck – Bank of America Merrill Lynch: Sure, I wanted to go into the commentary you made earlier about trying to deepen the relationships with existing customers and the Centennial have (inaudible). I guess, what percentage of your customers do you feel like you have this opportunity to really go in and add a meaningful new business line and then where are you in that process? And it sounds like, I mean, you have been doing this for a while, but it sounds like maybe you think there's maybe acceleration in those types of conversations.

Yeah, we do think that it's accelerating right now, and as hospitals prepare themselves for whatever the ramifications of the accountable care at our, they prepare themselves to be more medical homes whatever that mean, et cetera. So, historically we have always done that, I mean, we do as you know pediatric intensive care is something that we have done for decades, newborn nursery. Well, newborns is another thing that we've done for a long time. Now, hospitals are saying, can we do pediatric hospital, so, can we run a pediatric ER, and we have some of those across the country and in Vegas and in other places. I think it's just a matter of helping the hospital think through their strategies, and helping them with the physician component of the services that they want to add. I think it's a good opportunity for us. I think that given the relationships that we have with a lot of our hospital clients, I think that we'll see some valuable increase in those opportunities. Kevin Fischbeck – Bank of America Merrill Lynch: And I guess and some of the metrics were pretty good in Q4, but maybe a little bit counter to what I might have thought. The volume number was good on the NICU side. But the payor mix is going in the wrong direction. I would have thought that volume for getting better it would be the commercial volume that's coming back through. Do you have any sense of why it's not going that way?

Now, you're looking at it exactly the way that I was looking at it. I was thinking that if volumes started to come back, that it would be more on the commercial side. But that's not what's happening. I don't have any explanation for that. Kevin Fischbeck – Bank of America Merrill Lynch: And tell me whether it's relates to what you do to the service line or maybe you are getting into something that is more (inaudible)?

That's too significant of a ship for that to happen.

Yeah. Kevin Fischbeck – Bank of America Merrill Lynch: Okay, and then last question, same store pricing actually was okay, will improve sequentially, despite the payor mix shift getting a little bit worse. How do we think about what happened there? Is that – are you seeing a little bit better commercial pricing that might flow through the next year? Or how do you think about that?

Yeah, we continue to be able to renegotiate these contracts and although it is never an easy thing to do, it is a thing that we put our plan together at the beginning of the year and what contracts need to be renegotiated and we go out and do that. I would say that in general terms, things are about the same as they've been in the past. And because of the contracts, do have escalators built into them over, you know, year-over-year, we feel pretty comfortable in saying that, it looks to us like this pricing growth will continue over the foreseeable two or three years. Kevin Fischbeck – Bank of America Merrill Lynch: Okay, all right. Great, thanks.

Thank you.

Thank you. Our next question comes from the line of Gary Taylor with Citigroup. Please go ahead. Gary P. Taylor – Citigroup Global Markets Inc.: Hi, good morning everybody.

Good morning.

Hi Gary. Gary P. Taylor – Citigroup Global Markets Inc.: A couple of questions. First on the same-store revenue growth in the guidance for the first quarter 1% to 3% coming off this pretty strong 3.1% this quarter. I know you are, I guess contemplating in that range, potential for some more payor mix shift, but anything else as to why you are guiding more conservatively, sequentially?

No, we are just cautious about; we are just not ready to call this situation over. So we just want to be cautious about how we guide you. Gary P. Taylor – Citigroup Global Markets Inc.: Got it. And when you talk about, I guess historically whenever you talk about government payor mix shift that was always in the neonatal business, commercial moving to Medicaid which obviously paid dramatically lower levels. And I presume when you talk about that shift that's still what we are talking about because obviously every anesthesia deal you do also have lower Medicaid, but has obviously Medicare. So, just doing an anesthesia deal, I think takes the consolidated payor mix towards government pay. So when you have the commentary about the sequential changes and mix shift, are we still primarily talking about Medicaid growth in neonatal?

Primarily Gary, so obviously there is some, as you mentioned, Medicare business on the anesthesia side, some Medicaid, but very slight. So there is a slight piece of it, but, yes the predominance of it is still as you described it. Gary P. Taylor – Citigroup Global Markets Inc.: And am I right, I mean in general your average anesthesia practice Medicare and Medicaid together would be a higher percent of revenues than just this NICU Medicaid percent of revenues, right?

No, I wouldn't say revenue. If he is talking about volume, the answer is probably 50-50 depending on the practice, but not on a revenue basis. The bulk of the revenue comes from managed care.

Our payor mix is better I guess is what. Gary P. Taylor – Citigroup Global Markets Inc.: Right, I guess, I was thinking you probably have similar to a hospital mix of maybe 30%, 35% Medicare, 10% Medicaid, but have you ever – have you guys ever disclosed kind of where Medicare and Medicaid is for anesthesia percent of revenue?

No, we haven't but the Medicaid piece is low. Gary P. Taylor – Citigroup Global Markets Inc.: Right, okay.

Yeah. Gary P. Taylor – Citigroup Global Markets Inc.: Last question, I just, I think you, I think you said this, and I just wanted to clarify. So the $144 debt that's on the balance sheet as of the end of the fourth quarter, that includes all the deals including Chattanooga, which got announced in January but closed on 12/31, all those are in that figure.

Yes, whatever we had outstanding right as of year end. Gary P. Taylor – Citigroup Global Markets Inc.: Got it.

Whatever we paid for. Gary P. Taylor – Citigroup Global Markets Inc.: Right, and I do. Sorry, I had one more question. Can you – Roger, can you remind us, what's going on in pediatric cardiology? I know some of the office-based volumes have been weaker for a few years, and I guess the smaller piece and I have just kind of forgotten what's driving some of the trend there.

Gary P. Taylor – Citigroup Global Markets Inc.: Okay, great thank you.

Yeah.

Our next question comes from the line of Darren Lehrich with Deutsche Bank. Please go ahead. Darren Lehrich – Deutsche Bank: Thanks, good morning everybody.

Good morning. Darren Lehrich – Deutsche Bank: .:

Well, once I get the first money in the door then we can revisit that. But, right now, it's cash, because I haven't seen any of it yet, and the plans are into exactly how it's going to work on a state-by-state basis. So Darren we'll continue to revisit that. But, at the being, I can't tell you that I'll do anything other than cash.

There's so much some certainty. With all of the different states right now, each one talking about doing it differently, and having their own methodology et cetera that it's just really hard to get the auditors to sign off on doing anything. Darren Lehrich – Deutsche Bank: Yeah. All right. I hear you. I guess for us where some of us are trying to make reason, (inaudible) on that. I mean, I guess do you just think it's a bad idea to include it for 2013. I know you are not including in your guidance but, do you still think it's entirely probable that you know you're going to see all that money in 2013.

, : Darren Lehrich – Deutsche Bank: Okay. And then I wanted to go back, Roger. You talked about the market partnerships like you're doing in Centennial and Nashville. I guess, just to clarify, as we see more of those going forward. Is that going to be included in your same-store pediatric metrics, how are you going to be, I guess characterizing the growth from those situations?

Well, I don't think that we would include that in our same-store calculation. Vivian…

Yeah, some to them, if it's a program that's in an existing unit potentially could be, but the majority of them probably are not, and so if it's a new program that's a standalone program then it would not be. Darren Lehrich – Deutsche Bank: Okay. That's helpful, and then couple of other things here. I just wanted to go back to the variability of margins in your commentary. I mean I think you've been very clear about business mix and payor mix, but I just want to make sure there is not something else that you're trying to message to us and maybe too much of a read into the comment. But are you suggesting that the practices, I guess own variability of margin, whether it's month-to-month, quarter-to-quarter, due to case loads or other factors in anesthesia is just something you're still trying to get a handle on or is it really just about the mix of the anesthesia business that you're acquiring, and how that impacts the overall numbers and then the care team model that might be different from one deal over the next. I guess, can you help me flesh that out, please?

Sure. So yes, it's really more about the change in the mix of practices. So there is nothing more there, it's not really about variability in case mix or anything although obviously that impact just the overall same unit volume just like NICU would. And so for that piece, Darren it's not really any different. I think the discussion with the margins that we are trying to drive home is just the change in our business mix, which does impact the margins and coupled with that on a same unit basis. It just depends on what's happening with that volume and pricing and at any given time. And so, obviously, the 120 basis points for the year on the [P mix] is a lot to swallow and in spite of that we still had net reimbursement growth, but nonetheless, it's a big nut to crack and so that's happening on that side of the house. In addition to just expanding some of these other service lines, which obviously the biggest part of it is anesthesia, but there is other of these service lines as well. Darren Lehrich – Deutsche Bank: Okay. And I guess just on that just helping us think through. You gave us the 27% of revenue is anesthesia. I think that's the number that we're going to see in the K for the calendar year that compares to 21% last year. What was it on a run rate basis in Q4, because I think to what you're saying here about variability in business mix, I think it would just be awfully helpful to us to level set that and so in Q4 what was the mix, was it 27% or can you give us a sense for what it was?

I mean remember that as Roger mentioned a lot of these big deals just happened basically at December 31, December 21. So for the most part in 2012 that included what we had done, because the other two deals at the end of the year don't have much revenue to them and one doesn't have any. Darren Lehrich – Deutsche Bank: Okay. So maybe I'll take another stab. What was the trailing revenue that you acquired in 2012 and how did that breakout between anesthesia and pediatrics?

I mean other than this, percentage that basically is. It's a 6% increase from 2011. Darren Lehrich – Deutsche Bank: For the year?

Yeah, right when we talk, when we disclose this, that you guys will see it soon when we file our Ks, it's a same table that we had in there last year. So it's roughly a 6% increase and that's basically for the whole year. Darren Lehrich – Deutsche Bank: Got it, okay. So we're just going to get the annual numbers I guess, is what you're saying?

Yes. Darren Lehrich – Deutsche Bank: Okay. And then the last thing here is just on managed Medicaid, I was hoping to get just a brief update Roger. A lot of states had big growth in 2012. And I'm just curious how that's played out for you, any change that you're seeing from that trend?

No, really managed Medicaid has no impact on us. We are able to generate the same kinds of revenue from either traditional or managed Medicaid. That has no impact whatsoever. Occasionally, you can get a little bit better – half a percent better or something because of the cut in the administrative hassles. But it's basically the same. Darren Lehrich – Deutsche Bank: Great. Okay, thank you.

Our next question comes from line of John Ransom with Raymond James. Please go ahead. John W. Ransom – Raymond James & Associates, Inc.: What did I do to get pushed a way back here, the back of the line?

I don't know John. What's going on? John W. Ransom – Raymond James & Associates, Inc.: A lot of good questions, the open question I have is, as we think about second quarter and modeling what kind of puts and takes do we need to think about that are not in your first quarter numbers. I know you mentioned something to us – make sure we have a complete list of all those things that will not reoccur in the second quarter that are in the first quarter.

Well, I mean the bigger piece is just the seasonality. That's basically it. The other thing that I pointed out in this quarter, because I thought that it was a, that it really wasn't included in the average consensus if this idea that we do now have some debt, and so when I was looking at those line items that didn't seem to come through, and so we'll start paying some of that off, but depending on the acquisition activity you'll still see a big chunk of that in the second quarter. So that will remain. Other than that, like I said with parity right now, I'm just still waiting to see what happens with that. So I don't know, I think some of you guys potentially have that in there. I'm being cautious on that as... John W. Ransom – Raymond James & Associates, Inc.: Is there, other than states being sluggish and (inaudible) is there a structural reason, why you wouldn't be getting the new revenue by April 1?

Well, yeah because CMS has to approve those applications and so they have to go through that process. They have until March 31to file it, and then CMS has to review it, and see if they agree with their plans. John W. Ransom – Raymond James & Associates, Inc.: Okay. And so you'll just collect on cash, but potentially assuming everybody got approved you could have a big catch up cash payment in second or third quarter or something?

Yeah, we're hoping that right it suppose to be, as you know retro… John W. Ransom – Raymond James & Associates, Inc.: Yeah, yeah.

So we are hoping to get that and they have 90 days to review it. And so… John W. Ransom – Raymond James & Associates, Inc.: Okay.

As you know, I mean I don't know how long it will take, but they have 90. So doesn't mean that they'll meet the 90, but they have 90. John W. Ransom – Raymond James & Associates, Inc.: Right, right, okay. And then just lastly, exploring your payor mix for a minute. Historically, you've talked about commercial to Medicaid on the neonatal side being something like 5 to 1. Is that still a good way to think about it as you shift a 100 basis points it's like losing 80% of the revenue on an apples-to-apples basis is that a good way to think about it?

I think we've said over 3 to 1 if I recall yes, but I don't recall it being 5 to 1. John W. Ransom – Raymond James & Associates, Inc.: Okay, so 3 to 1 and what about on the anesthesia side the difference between Medicare and commercial, what does that look like now?

Well, remember for anesthesia they get paid even though it's Medicare and they get paid a lot less than the other Medicare payments, and so it's roughly about the same Karl is it.

Yeah, the differential I mean the ASA will say that Medicare is about 33% of the average commercial reimbursement. John W. Ransom – Raymond James & Associates, Inc.: Yeah.

So I mean that's kind of a baseline you can use that's really going to vary based upon the state situations as far as with managed care situations, but I think that's a good number to use. John W. Ransom – Raymond James & Associates, Inc.: Are we seeing any email address (inaudible) I missed it, but is the payor mix in anesthesia fairly stable?

Well, the payor mix in anesthesia has had some slight increases as well but not I mean obviously as I think Gary asked me this shift is predominantly pediatrics, but there is a slight shift in anesthesia but not it just not that weighted here. John W. Ransom – Raymond James & Associates, Inc.: Okay, and then lastly this is for the CEO. Hi, Roger I know what you talked about with your hospital partnership, but could you just expand on that a little bit are we on a 1 to 10 is this is an aid, is this is a three how many potentially hospital partners of yours are eligible for this kind of partnership, what does that mean in terms of taken the revenues from X to Y not that we are going to put in the model and start beating you up to demand that. But how significant could this be as you move into doing more stuff for your partners?

Well, I think it just one more tool that we have, I would say, right now, I mean just totally off the top of my head, and maybe it's a five, as far as hospitals where we might have opportunities to help them out with. What's changing and is the volume of hospitals that are now wanting to talk to us about this, and in some areas even the specialties, pediatric surgery is one, for example. As you know, last year we acquired two different pediatric surgical groups, that's a new specialty for us, and that is driven by the hospitals. There is a small number of pediatric surgeons, and hospitals compete with them, et cetera. So, that's one area where I think we'll see some increased opportunities, and then the rest of it is really like I said, it's either hospitals that want to open up the ICUs, or that are unhappy with their group of pediatric hospital lists, or that group is on [Orlando] late last year is an example of that. John W. Ransom – Raymond James & Associates, Inc.: Now, are you, do you see yourself getting into any of the sharing arrangements with payors and hospitals and going sub-capitation, or do you see yourself being, I mean, three yeas from now are you still going to 99% fee for service.

Yeah, we've haven't talked about that. I mean we are not getting any requests to do that, and we're just not going down that path at all at this point in time. John W. Ransom – Raymond James & Associates, Inc.: Okay, thank you.

Thank you.

Thank you. Our next question comes from the line of Rob Mains with Stifel Nicolaus. Please go ahead. Rob Mains – Stifel Nicolaus: Yeah, given John Ransom to comment I'm wondering whether this is age discrimination putting (inaudible).

We asked about a (inaudible) by there. Rob Mains – Stifel Nicolaus: Okay. Just a couple of kind of mop-up type question. G&A, Vivian, was up $2 million sequentially, is there anything in the fourth quarter that was unusual or is that kind of a run rate we should use going forward?

Yes, well, we did all those deals, so I got expense those acquisition costs and there's not, as we said some of those don't even have any revenue in the fourth quarter. So, yes, we did have a lot of acquisition costs related to the deal flow. Rob Mains – Stifel Nicolaus: Okay. And you are not thinking of breaking out transaction costs?

No way, it's not material enough to do it, but I mean if you want to know – I mean year-over-year, it was up roughly at the fourth quarter over 600,000. Rob Mains – Stifel Nicolaus: Okay. And then tax rate what should be, we'll be using to model again this year? And will it that be, as has been last few years kind of higher in the first quarters and then drift down?

Yes, so, yes, it will be. And what I am saying is that the tax rate for the year will be consistent with what you saw in 2012. So I think it was 3794 something in that period. Rob Mains – Stifel Nicolaus: Yeah, Okay and then last Medicaid parity question. Are you getting any kind of indication of states just want you to pass on it, not taking part?

No. Rob Mains – Stifel Nicolaus: Okay, all right. That's all I have. Thank you.

Thank you.

Thank you, Rob.

We have no more questions in queue.

Okay. Thanks very much for joining. More questions, I appreciate everyone's attendance this morning and I look forward to speaking with you next quarter. Thank you, operator.

Thank you. And ladies and gentlemen that does conclude our conference for today. Thank you for your participation and for using AT&T Executive Teleconference. You may now disconnect.